A comprehensive study of modified three-month pediatrics training curriculum at Shahid Beheshti University of Medical Sciences and its impact on student satisfaction.

OBJECTIVES: Continuous curriculum improvements reveal the dedication of policy-makers to raising the quality of education and student learning. This study aims to report the impact of curriculum changes to the three-month pediatric course curriculum at Shahid Beheshti University of Medical Sciences (SBMU) on the satisfaction levels of medical students. METHODS: One hundred eighteen 4th-5th years medical students, who had completed their pediatric clinical rotation in SBMU-affiliated teaching hospitals including Mofid Children Hospital, Loghman Hakim Hospital, Shohada-e-Tajrish Hospital, and Imam Hossein Hospital from January to December 2022 were included in this cross-sectional study. After obtaining informed consent, a questionnaire was sent out to all participants, that included 27 statements about the impact of the modified curriculum on their satisfaction with their learning and performance. SPSS version 22 was used to analyze the data. RESULTS: The level of satisfaction of trainees from attending clinics was 82-56%, prior introduction to the course was about 82%, and attending general hospitals (all hospitals except Mofid Children hospital, which is the only children hospital affiliated to SBMU) was 82-97%. The quality of patients-based learning was reported in terms of attendance at morning report sessions which was 92.3%, attendance at ward rounds, which was 71.8%, and attendance at clinics, which was 62.4%. The satisfaction rate from the senior attending mentor was 96.5%. The satisfaction rate of the pathology course was 67.2%, and the radiology was 82.4%. The satisfaction level of medical students from the infectious disease department was 70% and the gastroenterology department was 83.8%. The level of satisfaction with the implementation of the twelve-week program was 68.7%, with the expressiveness and usability of the presentation of materials was 53.9%, with the compatibility of the exams with the presented materials was 92%, and withholding weekly exams was 86.8%. The satisfaction rate of using the materials presented in the final exam in the digestive department and the infectious department was 85% and 68%, respectively. The overall satisfaction rate of the training course was 76.66%. CONCLUSION: The results provide vital insights for improving medical education. According to this study, medical student satisfaction with the pediatric curriculum after its recent revisions was in a satisfactory range. Attendance at clinics, information sharing, patient-based learning, practical training, attending mentorship, curriculum clarity, and alignment with student expectations all contributed to participants' high levels of satisfaction.

Giant non-parasitic splenic cyst: a case report.

BACKGROUND: Splenic cysts are quite rare and asymptomatic. They may result from infection by a parasite, especially Echinococcus granulosus (hydatid cyst), or from non-parasitic causes. Since primary splenic cysts are not common, simple cysts can be misdiagnosed with a hydatid cyst in endemic areas. CASE PRESENTATION: We reported a 14-year-old Iranian girl initially presented with a vague abdominal pain, which progressed to left shoulder pain, fullness, early satiety, and shortness of breath and remained undiagnosed for 7 months despite seeking medical attention. Finally, imaging revealed a massive splenic cyst measuring 220 mm × 150 mm × 160 mm raising concern for a hydatid cyst due to regional endemicity. Consequently, the patient underwent total splenectomy. However, histopathological examination surprisingly revealed a simple non-parasitic cyst. CONCLUSIONS: Detecting rare simple spleen cysts requires early ultrasonography (US) and careful reassessment of diagnoses for non-responsive or worsening symptoms. Distinguishing them from splenic hydatidosis, especially in endemic areas, demands thorough paraclinical evaluations and patient history regarding potential parasitic exposure. While total splenectomy is the primary treatment for these huge cysts, the optimal surgical approach should be tailored case by case. These insights emphasize a comprehensive diagnostic approach to enhance accuracy and optimize patient care for these uncommon cysts.

A pediatric case series of catastrophic gastrointestinal complications of posttransplant lymphoproliferative disease with increasing incidence, high association with coronavirus disease 2019, higher mortality, and a plea for early endoscopy to prevent late fatal outcome.

BACKGROUND: Posttransplant lymphoproliferative disorder is one of the most severe complications after transplantation, caused by uncontrolled proliferation of Epstein-Barr virus-positive B-cells in the setting of chronic immunosuppression. As one of the biggest transplant centers worldwide, we observed a potential increase in the number of patients with posttransplant lymphoproliferative disorder presenting with gastrointestinal symptoms in 1 year, during the coronavirus disease 2019 pandemic. There is limited information about dysregulation of the immune system following coronavirus disease 2019 infection, which may lead to Epstein-Barr virus reactivation in Epstein-Barr virus-positive B-cells and development of posttransplant lymphoproliferative disorder. Furthermore, there is no consensus in literature on a modality that can help in early diagnosis of posttransplant lymphoproliferative disorder with nonspecific gastrointestinal presentations before late and fatal complications occur. CASE PRESENTATION: Our case series includes five Iranian (Persian) patients, three female (2, 2.5, and 5 years old) and two male (2 and 2.5 years old), who developed gastrointestinal posttransplant lymphoproliferative disorder after liver transplantation. All of our patients were on a similar immunosuppressant regimen and had similar Epstein-Barr virus serologic status (seronegative at time of transplantation but seropositive at time of posttransplant lymphoproliferative disorder diagnosis). Four patients had either a positive coronavirus disease 2019 polymerase chain reaction test or exposure within the family. Although all of our patients presented with nonspecific gastrointestinal symptoms, four patients developed late posttransplant lymphoproliferative disorder complications such as bowel perforation and obstruction. All five patients with gastrointestinal posttransplant lymphoproliferative disorder received chemotherapy, but only two survived and currently are continuing the therapy. In one of the surviving patients, prompt endoscopic investigation resulted in early diagnosis of posttransplant lymphoproliferative disorder and a better outcome. CONCLUSION: Since 80% of our patients had exposure to coronavirus, a potential relationship might be suggested between the two. Furthermore, as we witnessed in one case, urgent endoscopic investigation in immunocompromised patients presenting with gastrointestinal symptoms can improve the clinical outcomes and therefore should be considered for early diagnosis of posttransplant lymphoproliferative disorder.

Evaluation of Outcomes and Complications of Large Volume Paracentesis without Albumin and Coagulopathy Therapy in Pediatrics with Severe Ascites.

Background: Large-volume paracentesis has become the first treatment choice for patients with severe and refractory ascites. The studies have reported several complications after therapeutic paracentesis. But there are few published data on the complications with or without Albumin therapy. We aimed to analyze the safety and complications of large-volume paracentesis in children with or without albumin therapy. Methods: This study was conducted on children with severe ascites with chronic liver disease who underwent large-volume paracentesis. They were divided into albumin-infused and albumin non-infused groups. In the case of coagulopathy, no adjustment was made. Albumin was not administered after the procedure. The outcomes were monitored to evaluate the complications. To compare two groups, a t-test was utilized, and the ANOVA test was used to compare several groups. If the requirements for using these tests were not met, Mann-Whitney and Kruskal-Wallis tests were applied. Results: Decreased heart rate was observed in all time intervals and was meaningful six days after paracentesis. MAP also decreased statistically at 48 hours and six days after the procedure (P < 0.05). Other variables did not show any meaningful change. Conclusion: Children having tense ascites with thrombocytopenia, prolonged PT, Child-Pugh class C, and encephalopathy can undergo large-volume paracentesis without any complication. Albumin administration before the procedure in patients with low levels of Albumin (<2.9) can effectively overcome the problems of tachycardia and increased mean arterial pressure. There will be no need for Albumin administration after paracentesis.

Chylous ascites as a rare complication of abdominal trauma in a 7-year-old girl: A case report.

Key Clinical Message: Abdominal trauma can be one of the causes of chylous ascites in pediatric cases, along with tuberculosis and malignancy. However, a definitive diagnosis is more reasonable to be done by excluding other causes. Abstract: Chylous ascites (CA) is a rare type of ascites. Though it has high mortality and morbidity rates, which usually happen due to the rupture of lymph vessels into the peritoneal cavity. Congenital abnormalities, including lymphatic hypoplasia or dysplasia, are the most causes in pediatrics. CA following trauma in children is very rare, and to the best of our knowledge, there are very few reports in this regard. Here, we report a 7-year-old girl who was referred to our center with CA after a car accident.

Questioning Diagnostic Value of Serum Matrix Metalloproteinase 7 for Biliary Atresia.

Background: Matrix metalloproteinase 7 (MMP7) has been suggested as a promising biomarker in diagnosing biliary atresia (BA). This study aimed to assess the diagnostic accuracy of serum MMP7 in BA in the Middle Eastern population. Methods and materials: In this cross-sectional study, neonates and infants with direct hyperbilirubinemia admitted to Namazi referral hospital, Shiraz, Iran, were studied. Baseline demographic and clinical characteristics and blood samples were obtained on admission. MMP7 serum concentration was measured using an enzyme-linked immunosorbent assay (ZellBio GmbH, Ulm, Germany). Results: 44 infants with a mean age of 65.59 days were studied. Of these patients, 13 cases were diagnosed with BA, and 31 cases' cholestasis related to other etiologies. Serum MMP7 concertation was 2.13 ng/mL in the BA group and 1.85 ng/mL in the non-BA group. MMP7 was significantly higher in those presented with either dark urine or acholic stool. The predictive performance capability of the MMP7 was not significant in the discrimination of BA from the non-BA group based on receiver operating characteristic curve analysis (area under curve: 0.6, 95% confidence interval: 0.45-0.75). In the optimal cut of point 1.9, the sensitivity and specificity were 84.6% and 45.1%, respectively. Further combination of MMP7 with Gamma-glutamyl transferase (GGT), alkaline phosphatase, direct and total bilirubin, and dark urine or acholic stool was not remarkably boosted the diagnostic accuracy of the test. Interestingly, GGT at a cut-off point of 230 U/L was 84.6% sensitive and 90.3% specific for BA. Conclusion: Our results are not consistent with previous studies on this subject. Considering more conventional and available tests like GGT besides conducting future studies with greater samples and different geographical areas is recommended.

Manifestation of leech infestation as severe gastrointestinal bleeding in a 3-year-old boy: a case report and review of the literature.

BACKGROUND: Leeches are a class of hermaphroditic parasites that can attach to various body parts and start sucking blood. Gastrointestinal (GI) bleeding due to leeches is a rare phenomenon that is more common in less developed countries. Common symptoms include melena, hematemesis, pallor, weakness, and fatigue. Due to the similar symptoms of this issue to the main differential diagnoses of GI bleeding in pediatrics, such as diarrhea, constipation, diverticulitis, esophagitis, and anal fissures, it is challenging to differentiate it from the rest. CASE PRESENTATION: We present a three-year-old boy who was transferred to our center with hematemesis, tarry stool, and a drop in hemoglobin level. He finally was diagnosed with a leech in his stomach. CONCLUSIONS: In less developed counties, the inability to reach safe drinking water, swim in lakes or springs, and inadequate awareness of public health information among individuals can be risk factors for leech infestation.

Aplastic anemia: a new complication in the recent mysterious hepatitis outbreak among children worldwide: two case reports.

BACKGROUND: Recently, an unknown hepatitis outbreak among children has concerned many individuals worldwide. These cases are frequently reported, mainly from Europe and other countries. In this study, we present two similar patients, who, to the best of our knowledge, are the first cases reported in the Middle East (Shiraz, Fars Province, Iran). Unlike in similar cases reported up until 30 April 2022, our patients' hepatitis eventually resulted in aplastic anemia. CASE PRESENTATION: In this study, we present cases of two Iranian boys aged 13 and 8 years with hepatitis of unknown origin who developed aplastic anemia in the course of hospitalization. CONCLUSIONS: Hepatitis-associated aplastic anemia is a well-known immune-mediated form of aplastic anemia that we detected in our patients and treated with immunosuppressive therapy. One patient established a satisfactory response to the treatment, but unfortunately, the other was declared brain dead.

Rosa damascena together with brown sugar mitigate functional constipation in children over 12 months old: A double-blind randomized controlled trial.

ETHNOPHARMACOLOGICAL RELEVANCE: Rosa × damascena Herrm., known as damask rose, is a bushy shrub that is found abundantly in Fars province, Iran. This species has been used in Iranian traditional practices for the treatment of abdominal pain and constipation, as gastrointestinal diseases. Brown sugar (Saccharum officinarum L.) has also shown laxative effects in pediatric patients with functional constipation. AIM OF STUDY: This study aimed to compare the effects of Polyethylene Glycol (PEG) and a syrup made of R. damascena and brown sugar on the treatment of functional constipation in children aged above 12 months. MATERIALS AND METHODS: This double-blind randomized clinical trial was performed on 100 patients. One group received PEG and the other received an herbal syrup containing the decocted extract of 0.1 g R. damascena petals mixed with 0.85 g brown sugar per 1 mL. The patients were followed up for two and four weeks and their progresses were recorded. RESULTS: The cure rate was 100% in the R. damascena group and 91.7% in the control group. R. damascena and brown sugar syrup had an odds ratio of 1.09 in the treatment of functional constipation compared to PEG, but the difference was not statistically significant. The only adverse effect detected in the R. damascena group after four weeks was the bad taste of the medication that was too sweet. Nonetheless, this could be solved during the pharmaceutical processes. CONCLUSION: The R. damascena extract and brown sugar syrup can be used as an effective, safe, and inexpensive agent in the treatment of functional constipation.

Investigating the barriers to clinical education among medical students in Iran: A narrative review study.

Various factors can affect the clinical education of medical students. The main purpose of this study was to investigate the barriers to clinical educational related to medical students in Iranian universities of medical sciences. To conduct this study, all studies related to the subject under discussion, during the years 2000-2022, by systematically searching internationally available databases including Web of Science, Science Direct, Scopus, PubMed, and Google Scholar, were reviewed. Finally, 14 fully relevant studies were selected to investigate the main objective. The results of the present study showed that some factors, such as clinical environment, educational programs, facilities and equipment, number of students, how teaching professors, educators and hospital staff interacted with students, motivation and interest of students, hope for the future, job security and other similar parameters could affect the quality of clinical education. Based on the results of the present study, it can be concluded that the quality of clinical education in different universities of medical sciences is different and depended on many factors. Furthermore, it is necessary for the educational administrators of medical universities in Iran to identify the needs and shortcomings related to the clinical education of universities and then remove those barriers.

Is It Stevens-Johnson Syndrome or MIS-C with Mucocutaneous Involvement?

BACKGROUND: Severe acute respiratory syndrome coronavirus-2 (SARS-COV-2) can be present in the form of multisystem inflammatory disease in children. Case Presentation. A 25-month-old boy presented with fever, malaise, diffuse maculopapular rashes, and mucosal involvement during the COVID-19 pandemic. He was first diagnosed with Stevens-Johnson syndrome (SJS). Further evaluation revealed lymphopenia, thrombocytopenia, and elevated levels of C-reactive protein (CRP), ferritin, and fibrinogen. This was followed by a positive polymerase chain reaction (PCR) test for COVID-19. In addition to receiving initial care for SJS, he was treated for MIS-C, which led to his recovery after four days. CONCLUSION: COVID-19 infection should be considered in children with fever and dermatological features during the pandemic because it may cause different features of the multisystem inflammatory syndrome in children (MIS-C), suggestive of delayed hyperimmune response.

Non-celiac gluten sensitivity as a rare cause of growth retardation in children: a case series study.

AIM: Herein, we present five children and adolescents with a final diagnosis of non-celiac gluten sensitivity (NCGS). BACKGROUND: Non-celiac gluten sensitivity (NCGS) is a condition characterized by gastrointestinal and extra-intestinal symptoms triggered by ingestion of gluten-containing compounds, e.g., wheat, rye, and barley, in subjects without celiac disease or wheat allergy. METHODS: Demographic characteristics, clinical manifestations, serum biomarkers and skin prick test were evaluated. Patient data was also recorded after they followed a gluten-free diet (GFD). Height and weight were measured, and all patients were examined 6 months after following the suggested GFD. RESULTS: All patients had failure to thrive and abdominal pain. Clinical symptoms were reduced, and significant weight and height gains were detected after 1 month of following a gluten-free diet. CONCLUSION: The relationship between failure to thrive (FTT) and NCGS is still unknown; hence, NCGS may be one of the main causes of FTT which can be prevented by gluten-free diets.

Acute Pancreatitis as a Possible Unusual Manifestation of COVID-19 in Children.

Coronavirus disease-2019 (COVID-19) which is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has spread throughout the world causing problems for millions of people. Symptoms of COVID-19 in pediatric patients include both respiratory and gastrointestinal symptoms. The most common symptoms are fever, cough, and fatigue. In this report, we describe a case of a previously well 14-year-old boy, who presented to our emergency department with a complaint of abdominal pain, nausea, and vomiting without fever or respiratory symptoms. He was diagnosed with acute pancreatitis based on an abnormal amylase level and abdomen computed tomography (CT) and later found to be infected by SARS-CoV-2, by a positive reverse transcriptase-polymerase chain reaction (RT-PCR) test.

Clinical guidelines for traumatic brain injuries in children and boys.

The main aim of management of pediatric traumatic brain injury (TBI) is to hold normal ranges for optimizing the most proper outcomes. However, to provide physiologic requirements to an injured brain it is very important to enhance the quality of recovery and minimize secondary injuries. The aim of study is to identify proper guidelines to manage pediatric TBI. A comprehensive research was conducted on biomedical and pharmacologic bibliographic databases of life sciences, i.e., PubMed, EMBASE, MEDLINE, LILACS database, global independent network of Cochrane, Science Direct and global health library of Global Index Medicus (GIM) from 2000 to 2019. Main objective of this study was to provide a comprehensive review of available clinical practice guidelines for TBI. These guidelines can be administered to a pediatric population to improve the quality of clinical practice for TBI. These guidelines could be applied worldwide, despite different traditional demographic and geographic boundaries, which could affect pediatric populations in various ranges of ages. Accordingly, advances in civil foundations and reforms of health policies may decrease pediatric TBI socioeconomic burdens.

Survey of efficacy of pediatric appendicitis score in Iranian patients less than 18 years old referred to the emergency department.

INTRODUCTION: Abdominal pain, in particular appendicitis, is a common cause of emergency department visits in children. Therefore, early diagnosis is very important. There are different scoring systems for the diagnosis of appendicitis. This study is the first study to evaluate the performance and accuracy of pediatric appendicitis score (PAS) in Iranian children with abdominal pain in emergency departments. METHODS: This is a cross-sectional study of children under 18 years with suspected appendicitis who were referred to the emergency medicine department of hospitals affiliated to SBMU during 2015. Acute appendicitis was determined according to pathological findings, and final PAS scores were calculated for all children. With statistical analysis, comparison between two groups was calculated and the diagnostic accuracy of PAS score was estimated. RESULTS: 88 children with mean age of 10.5 ± 3 were studied. According to clinical examination 58 of the children were suspected to have acute appendicitis and 30 others were healthy. In current study, the diagnostic accuracy and precision of PAS at cutoff of 5.5 in patients younger than 18 years admitted to the emergency department with suspected acute appendicitis was 91% and 92%, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value were 93.88%, 86.21% and 92%, 89.29%, respectively. CONCLUSIONS: The results of current study showed that PAS has high diagnostic predictive value for the diagnosis of acute appendicitis in children under 18 years and due to the advantages listed for this score, its use is recommended for children in emergencies.

Prevalence of multiple birth in Isfahan, Iran.

BACKGROUND: According to increasing rate of using assisted reproductive technology (ART) which result in higher rates of multiple birth and natal difficulties, we aimed to determine the prevalence rate of multiple birth pregnancies. MATERIALS AND METHODS: A descriptive cross-sectional study evaluating birth files in 2009-2010 of main hospitals of Isfahan, Iran. RESULTS: Among 31640 files' studies, 614 cases of multiple birth pregnancies were investigated. The product of these pregnancies were 1286 (50.2% females) infants including 557 twins (17.6/1000), 56 triplets (1.8/1000), and one case of quadruple (0.03/1000). Infants weigh <2500 g were 84.9% of all. Mothers had a mean age of 27.9 ± 4.9 which 30.4% of them had a positive history of using ART. CONCLUSION: The prevalence of multiple birth pregnancies is growing. The need for more mother and child care is important. Using ART world wide is leading more multiple birth which could be a cause for more complicated pregnancies.

Is thromboprophylaxis effective in reducing the pulmonary thromboembolism?

BACKGROUND: Deep vein thrombosis (DVT) is a relatively prevalent disease which causes high costs due to the required diagnostic tests, specialized treatments, and hospital admission. In recent decades, implementation of thromboprophylaxis protocols has significantly reduced the incidence of thromboembolism in hospitals. The present study aimed to compare the incidence of venous thromboembolism before and after implementation of the mentioned protocol in hospital with identified risk factors and underlying diseases. METHODS: In this case-control group, 385 patients at the risk of DVT, some before and some after implementation of the protocol were studied. Therefore, the level of thromboprophylaxis and the incidence of venous thromboembolism were compared before and after the protocol. Data was entered into SPSS(15) and analyzed by chi-square and t tests RESULTS: Out of 385 patients, 34 patients (8.8%) had venous thromboembolism while 351 (91.2%) were not affected. The incidence of venous thromboembolism was significantly different before and after the implementation of the protocol (17.7% vs. 5.9%; P < 0.001). The incidence of venous thromboembolism in patients not receiving thromboprophylaxis was almost 5 times higher than those who received it (20.7% vs. 5.1%). The frequency distribution of thromboembolism had a significant difference in the two above mentioned groups (P < 0.001). CONCLUSION: Thromboprophylaxis protocol reduced venous thromboembolism incidence in patients with underlying diseases which increase the risk of the complication.